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Ask the expert: Phil Toal Part 2
PETE GLADDEN
Pete’s World
Published: June 3, 2019
Last column was part one of my two-part “Ask The Expert “interview with Philip Toal, PT, DPT, OCS, C-OMPT, FAAOMPT, director of orthopaedic physical therapy residency at the Cleveland Clinic.
Here’s part two.
Q: What is the role of stretching and strengthening in patients with back pain?
A: I think a common myth is that LBP [low back pain] is a diagnosis that has a set protocol on how to get it better, or that all LBP is the same. In reality, there are different types of LBP, and also, each individual is different and needs a plan that matches their clinical presentation. For some patients who are stiff, stretching seems to be very helpful.
For those who are very flexible or have excessive mobility in their spines, strengthening seems to work great. I believe that we are typically trying to restore a balance of Mobility and Stability. If we are unbalanced, then that’s when we may become susceptible to low back pain.
Q: I know that I was expecting quick results based on the exercises and stretches you prescribed to me, but progress was slow and frustrating at times. But across two years I’ve seen amazing progress. Is this typical, or just specific to me?
A: Unfortunately, I would say your case is atypical, for the reason that most patients tend to abandon their programs too soon. You were ultra-diligent and compliant with your program, which is difficult for most of us.
There are some types of LBP, like yours, that required more stability. If the individual has higher level goals, like biking, rock climbing, or other intense sports, the demands on your body are greater. Gaining strength and stability tend to take a good amount of time and hard work. Other types of low back pain have the potential to get better very rapidly if the treatment is correct and matched to the patient’s clinical presentation.
Q: Based on the previous question, how prevalent is it for patients to get frustrated and quit on their rehab program?
A: Yes, it’s very common for patients to end their rehab too soon. That’s probably our default as humans, we tend to quit something when we don’t see results quickly. This is why we have New Year’s Resolutions that repeat themselves each year, or why the gym gets really busy in January, but by March it’s back to regular capacity.
We all want things to feel better very quickly, especially when we’re in pain, and I understand and empathize with that. It’s easy to get frustrated when you’ve had LBP for 2-3 months, trying to manage it on your own, and then start receiving treatment, and progress is slow.
As a clinician, maybe we need to take ownership of some of that frustration. We probably need to do a better job of educating patients on what our expectations and prognosis are. If I feel it’s a type of LBP that will take a few months to get better, I should inform patients early on, so they’re aware it’s more of a marathon than a sprint. This also ties back into goal setting for patient and clinician.
Q: Based on most of the PT routines that you formulate for people, how often are these routines that should remain a regular component of the patient’s lifestyle rather than just a temporary routine to be terminated when the patient’s feeling better?
A: Ideally, if it’s someone who’s going to be challenging their back with higher level tasks, like athletes, it’s probably a good idea to incorporate some of the program into their regular routine. I don’t think s/he would have to do all the exercises completed in therapy, but maybe just a select few that are still challenging.
If it’s a sedentary person who doesn’t work out regularly, I recommend some sort of general exercise routine. Maybe it’s walking, yoga, or doing a general strengthening program. We don’t have any research that back specific exercises are better than general exercise for preventing future bouts of LBP.
I think regular exercise is still one of the best ways to prevent injury as well as other medical issues, so I try to have my patients consider a realistic exercise program that they could enjoy doing.
If you’re interested in reading more about LBP, Phil’s blog is: https://knowmybodybest.com/